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  • 1. Winter 2012 / Volume 55, No. 1 Northwest Pharmacy Convention May 31st - June 3, 2012 Coeur d’Alene, Idaho Pg. 62012 Winter SeminarJanuary 8 - 10, 2012Westin Riverfront Resort and Spa, Avon, CO Pg. 32 Special Features Membership Northwest Pharmacy New Requirement for Highlights Convention CE Partcipants See page 4-5 See page 6 See page 27
  • 2. It’s your business. Only better.Understanding your business, and how every Leader® services and offerings help retail independent pharmacies:inch of your pharmacy makes money is • Improve reimbursementsessential during this critical time in our industry. • Streamline operations • Create alternate revenue streamsWith Leader®, our market-leading offering, we • Increase market shareare partnering with retail independents tohelp them be more successful now and into Seattle Distribution Center located at: the future. 801 C Street NW Auburn, WA 98001Become a partner today. Salt Lake City Distribution Center located at: 955 West 3100 South Salt Lake City, UT 84119 © 2009 Cardinal Health, Inc. or one of its subsidiaries. All rights reserved. Lit. No. 1LDR1280 (0409)
  • 3. WSPA Board of Directors President Julie Akers President-elect Brian Beach Immediate Past President Ron Williams Winter 2012/Volume 55, No. 1 Secretary/Treasurer Steve Singer Features board members Beth Arnold mEMBERSHIP 4 Kurt Bowen (Student) Why you should renew your membership Jill Carrier (Technician) Northwest Pharmacy Convention 6 Shaelah Easterday (Student) Register Today! Heather Ferguson Christopher Foley (Student) Legislative and Regulatory Affairs Council News 11 Melissa Hansen Legislative Update Andrew Heinz (Student) Kirk Heinz Legislative Day 12 Anne Henriksen Paul M. Iseminger (Technician) Greg Matsuura School News 13 Cindy Wilson Get the Latest WSU/UW Information Roger Woolf departments and specials managing editor Kathleen Goodner Continuing Education 21 Health Information Exchange 17 Publisher The Washington Pharmacy is owned and published Rx and the Law 31 by the Washington State Pharmacy Association Upcoming Events 32 to provide information, news and trends in the profession of pharmacy. Opinions expressed by the contributors, whether signed or otherwise, do not advertisersnecessarily reflect the attitudes of the publishers nor are they responsible for them. Subscription rate is $24 per year domestic / $59 foreign (including first Agility Recovery 31 class postage.) Bi-Mart 30 Per copy rate is $6. Cardinal Health 2 Washington Pharmacy ISSN (1539-1469) is published quarterly for $24 per year domestic / $59 Good Neighbor Pharmacy 18 foreign including first class postage by Washington McKesson 16 State Pharmacy Association at 411 Williams Ave. S, Pace Alliance 19 & 20 Renton, WA 98057. PERIODICALS Postage paid at Renton, WA and at additional mailing offices. Pharmacists Mutual 29 RxRelief 30 POSTMASTER Please send address changes to: Washington State Pharmacy Association 411 Williams Avenue S Staff Renton, WA 98057 Jenny Arnold, Director of Pharmacy Practice Development MISSION STATement The Washington State Pharmacy Association exists Danyal Henderson, Administrative Coordinator to advocate on behalf of its members to ensure pharmacy professionals are recognized, engaged Dedi Hitchens, Director of Government Affairs and valued as essential to the health care team. Kathleen Goodner, PR & Communications Manager Visit wspa’s website at Maria Lieggi, Membership & Education Administrator www.wsparx.org Jeff Rochon, Chief Executive Officer
  • 4. Why you Should renew today! IT’S YOUR FUTURE STRENGTHEN YOUR SKILLS Health care is in a dynamic state of Opportunities abound for you as a WSPA change. Decisions impacting pharmacy member. Participate in quality conferences, are made all the time. As the adage goes, seminars, and workshops that will contribute “If you are not at the table, you are on the to your continuing education and professional menu.” The WSPA is your invite to the table. development. Attending WSPA events helps Since health care reform is implemented to build your network and meet key players at a state level, it is crucial that you are in pharmacy, while learning about new and engaged and involved in those decisions. upcoming therapies, products, services, issues and developments. The WSPA is your voice to advocate for advancing the profession and protecting Whether you are looking for high-quality, timely your livelihood. CE that is relevant to your practice, or you want to learn about best practices from experts in AMPLIFYING YOUR VOICE your specialty, the WSPA has something for you. WSPA advocates for the profession on MAKE CONNECTIONS numerous levels to: strengthen and expand our role in patient care; protect WSPA provides opportunities to meet and access to pharmacy-provided services network with people in the pharmacy and products; and reinforce the value of profession. When you join the WSPA, you have pharmacies in ensuring patient safety and the opportunity to join one or more practicemember only information quality health outcomes. academies to connect with professionals from similar practice settings that allows you to: WSPA works within multidisciplinary • Solve problemsWSPA is the source for news and information about committees, patient advocacy groups, • Share ideasthe pharmacy profession and the members it serves, regulatory agencies, public health • Move your practice forwardand routinely provides members with relevant, jurisdictions, other professionalvaluable and timely information on the latest safety, associations, health insurance payers and WSPA academies include:regulatory and legislative news. Members receive: employers. • Ambulatory/Community Practice • Health Systems• Access to “Members Only” online Resource On a legislative level, WSPA works within • Independent Pharmacy Centers for Audit Avoidance & Protection, LRAC to ensure lawmakers understand the • Long Term Care Handling of Hazardous Drugs, Billing for Patient pharmacy profession. • Students Care Services, Compliance and Regulations, • Technicians Medication Safety, Medicaid, Medicare, Labor and Industries Resource Centers, Pharmacy Security, Whatever your practice setting or background, Non-English Communication Tools and much WSPA offers plenty of resources to build a more powerful network of professionals in pharmacy• Timely and valuable information via email alerts who can serve as mentors and support. and Washington Pharmacy, the association’s quarterly magazine The Washington State Pharmacy Association• WSPA Career Center and Salary Survey offers a comprehensive suite of benefits and• Quality On Demand Online CE services that give members of all practice• If you are Washington State Legislative and settings and career levels the tools they need Regulatory Affairs Council (LRAC) member, to succeed. Take a look at all WSPA has to offer you will also receive LRAC updates. It’s easy to and join your colleagues who are dedicated to become a member! Just mark the LRAC box on pharmacy. Become a member today! the membership form Together we are stronger! Washington State Pharmacy Association 411 Williams Avenue SouthFollow the WSPA on Facebook, Twitter, and LinkedIn! Renton, WA 98057 425-228-7171 Fax 425-277-3897 4 Washington Pharmacy www.wsparx.org
  • 5. Washington Pharmacy 5
  • 6. 6 Washington Pharmacy
  • 7. ConventionHotel Murano, Tacoma, WA
  • 8. Legislative Day 2012 T he 2012 Pharmacy Legislative Day was another huge success! Pharmacy’s pres- ence in Olympia was evident as more than 100 students in white coats from UW and WSU joined faculty members, alumni and pharmacy practitioners to advocate for the value of the pharmacy profession in impacting patient care. In a direct effort to advocate for the pharmacy profession, Jeff Rochon, Chief Executive Officer of the Washington State Pharmacy Association, Dedi Hitchens, Director of Government Affairs for Washington State Legislative and Regulatory Affairs Council and Lis Houchen, Regional Direc- tor of State Government Affairs for the National Association of Chain Drug Stores set the tone for several high profile speakers including: Lieuten- ant Gov Brad Owens; Senator Linda Evans-Par- lette, the only pharmacist legislator in Wash- ington; Jason McGill the Governor’s HealthCare Advisor; David Hanig, Senior Health Care Advisor for the Senate Democratic Caucus; Marty Brown, the Director of the Office of Financial Manage- ment; Senator Karen Kaiser, Chair of the Senate Health and Wellness Committee and Courtney Acitelli, Program Director for UW Impact. The day included 56 meetings with Senators and Representatives from across the state. Pharma- cists and pharmacy students addressed key bills such as Including Pharmacists in the Legend Drug Act, Pharmacist Provided Medication Review for Medicaid Managed Care Enrollees, PBM Transparency, e-Prescribing of CII Medica- tions and Increasing Penalties for Crimes Against Pharmacies. An event of this magnitude would not be pos- sible without dedicated volunteers and gener- ous sponsors. A special thank you to Kurt Bowen, Shaelah Easterday, Chris Foley, Nathan Deney and Andrew Heinz for coordinating the phar- macy student leaders. Thank you to Safeway for providing water and a big thank you to Bartell Drugs, Fred Meyer Pharmacy, and Spokane Pharmacy Association for providing the funding needed for the day’s event. Washington Pharmacy 11
  • 9. LRAC News By Dedi Hitchens, Director of Government Affairs T he 2012 Washington State legislative session began in Janu- Drug Act, SHB 2512 and SSB 6197, successfully moved past the sched- ary with a daunting $1.5 billion budget deficit despite a special uled legislative cut off dates and were voted on in both the House session prior to regular session. State lawmakers are required by and Senate. Both chambers voted and received unanimous support state constitution to fill the budget hole for the 2011-2013 supple- votes. During the second phase of the political process, legislators mental budget biennium. Regular Session came and went and the decided to move just one bill, SHB 2512. This bill was next in line for budget was not resolved so a second 30 day special session was called the Senate vote when three Democrats sided with the Republicans to in March. Here’s a summary of the flurry of activity and efforts by the successfully moved their proposed operating supplemental budget Washington State Pharmacy Legislative and Regulatory Affairs Council to the floor for consideration. This bold move occurred two hours (LRAC). prior to the 5 pm cut off and killed the bill and several others that needed to be voted on. The first few weeks of the legislative session was filled with policy committee hearings on policy bills. LRAC began the session with an Senate Budget Fireworks aggressive agenda including pushing for bills to create Pharmacy Ben- In an unprecedented move, the Senate Republicans took the reins of efit Manager (PBM) transparency requirements, include pharmacists the Democratic controlled Senate. The three Democrats sided with in the Legend Drug Act, and increasing penalties for crimes against the Republicans procedural move to circumvent the public hearing pharmacies. LRAC was successful in getting all of our bills heard in process and successfully moved their proposed operating supple- their respective committees. mental budget to the floor for consideration. The Senate is narrowly controlled by the Democrats with a small margin 27 Democrats to PBM Transparency 22 Republicans. Growing frustration with the Senate Democrats In the first year for this legislation in Washington State, LRAC success- proposed supplemental operation budget prompted the Republicans fully got this issue recognized by legislators. The PBM transparency to effectively gain control with the help of three Democrats, who bill had public hearings in both the House Healthcare and Wellness also have also expressed frustration over the Democrats budget. This Committee and the Senate Health and Long Term Care Committee. bold move occurred two hours prior to the 5 pm cut off and killed a Thank you to the LRAC members who testified in support of the PBM number of bills that needed to be voted on. Transparency Bill. LRAC members representing independent and chain pharmacy educated lawmakers about their experiences with The Senate Republicans, with a narrow vote of 25-24 successfully PBM’s. The hearing raised a number of questions and interest among passed their Operating Budget. This move shifted momentum in the lawmakers to look further into this issue. LRAC faced tremendous op- legislature, resulting in a Special Session. The Senate Republicans position from the powerful PBM lobby, and Insurance lobby. The PBM disagree with the Democrats’ proposal to delay payments to public lobby recruited PhRMA and a few employer groups to create confu- schools by one day – which is equivalent to $350 million. This delay sion for legislators. However, LRAC was successful in getting the issue in payment would have moved the budget deficit to the next budget heard in public hearings and now have some legislators interested cycle. The Republican budget cuts the Basic Health Plan and elimi- in investigating PBM practices. This is a new issue to most lawmakers nates the Disability Lifeline program. Both programs were preserved and one that can get confusing. This is going to be a long term effort under the Democrats proposal. Cuts to K-12 and Higher Education are and further work will be done educating lawmakers and executive also being proposed. policy staffers exposing PBM practices. LRAC will be working with the Chairs of the Senate and House Health Care committees organizing an House of Representatives’ Budget interim work session on PBM’s. The Washington State House of Representatives is a different story and is likely to give back some democratic leverage to the operating Increasing Penalties for Crimes Against Pharmacies budget negotiation. The House of Representatives does not have LRAC reintroduced a bill attempting to move the crime of robbing a such a narrow margin of Democrat control. The House Democrats are pharmacy from a second degree offense to first degree offense. This in the clear majority with a margin of 56 Democrats to 42 Republi- bill was met with concerns in the Senate over the costs of increas- cans. The Senate Republican’s budget is sure to run into road blocks ing incarceration periods. An amendment which still increases the in the House. LRAC successfully removed non-mandatory prescription penalties by making the crime of robbing a pharmacy a mandatory co-payments from the House’s proposed operating budget and we 12 month jail sentence was agreed upon. It also permits the court the fought off a professional license fee increase to fund the Prescription option to impose a stricter sentence based on consideration of the Monitoring Program. circumstances of the robbery. Unfortunately, the bill did get a fiscal note attached to it and that was the death of the bill. Under normal While politics is a tricky world where victories are often not apparent, legislative circumstances the fiscal note would not have been an issue, LRAC was very successful this year. Even though an unprecedented however, lawmakers are hard pressed to move forward on any bills Senate upheaval killed the bills, issues were heard and supported that have even a potential to fiscally impact the state. The good news, by legislators. LRAC’s voice is prominent and we have worked in col- Washington State’s pharmacy robberies have decreased over the laboration with provider associations, patient advocacy groups and years. However, LRAC still views this bill as important and will continue legislative leadership to recognize and support the role of pharmacy to try and get this bill passed. on the health care team. There is more work to be done as this ses- sion closes and LRAC is committed to work tirelessly throughout the Including Pharmacists in the Legend Drug Act interim to advocate for the pharmacy profession. There were two bills aimed at including pharmacists in the Legend12 Washington Pharmacy
  • 10. School News Construction of new building underway School News: Construction began in August 2011 on a new building in Spokane, “U.S. News & World Report” has ranked the UW School of Pharmacy’s which the College will share with the physician education program PharmD program 10th in the nation among all pharmacy schools. jointly administered by WSU and the University of Washington. The 2011 Washington Legislature allocated one-half the construc- The 2012 School of Pharmacy Don B. Katterman Lecture topic will tion funding for the building, and the College is anticipating the be Demonstrating Impact: Making the Case for Pharmacy Services. 2012 Legislature will provide the second half. It is a panel discussion in which the panelists will offer examples of how to improve health outcomes while also increasing revenue. Sources of funding to furnish and equip the new building – includ- The panelists are Washington State Pharmacy Association Director ing research laboratories, classrooms and space for faculty, staff of Pharmacy Practice Development Jenny Arnold, Walgreens Co. and students -- are being sought. The College will move its Pullman District Pharmacy Supervisor Daiana Huyen, Katterman’s Sand Point facilities to Spokane once the building is finished. Pharmacy Co-owner and Pharmacist Beverly Schaefer, and Virginia Mason Medical Center Administrative Director of Pharmaceuti- Pharmacy undergraduate summer research program receives cal Services Roger Woolf. The event is May 8th at 7 p.m. on the UW funding campus. A reception will take place beforehand at 6 p.m. CE credits are available. Visit www.pharmacy.washington.edu/katterman2012 Funding for an undergraduate summer research program in the for more information. College of Pharmacy has been renewed by the American Society of Pharmacology and Experimental Therapeutics. The Pharmaceutical Outcomes Research and Policy Program (PORPP) ASPET awarded the College $27,000 – or $9,000 per year – for the has created its first ever endowed directorship — the Stergachis next three years and has funded the program for nine of the last 10 Family Directorship. It is named after Andy Stergachis, professor of years, according to Raymond M. Quock, pharmaceutical sciences epidemiology and global health and adjunct professor of pharmacy, department chair. and his wife, JoAnn Stergachis, a sales executive with F5 Networks. Andy Stergachis was the founding director of PORPP and former The College must match the award with $5,000 per year, and the chair of the Department of Pharmacy. money allows student researchers to be paid a stipend for their 10 weeks of full-time work on research with a faculty mentor who is PORPP is also launching an online certificate program in health eco- an ASPET member. Additional College funds and various research nomics and outcomes research. Find out more at http://www.pce. grants and fellowships are used to allow more students and faculty uw.edu/certificates/health-economics/web-autumn-2012/. who are not ASPET members to also participate in the program. Faculty News WSU PharmD Class of 2015 Profile • 84 students Dean and Professor of Medicinal Chemistry Thomas Baillie has • 66 students have bachelor’s degrees received the 2012 Founders’ Award from the American Chemical • Average age is 25.3 years Society Division of Chemical Toxicology. The award will be presented • 57 females, 27 males at the ACS Fall National Meeting on August 19, 2012 in Philadelphia. • 56 students from Washington state As the Founders’ Awardee, Baillie will organize an award symposium • 10 students from California highlighting work in his area of research. • Other states represented are: Idaho, Oregon, Hawaii, Arizona, Texas, Utah, Colorado With the help of the UW Center for Commercialization, Professor of Medicinal Chemistry Dave Goodlett and Dr. Patrick Langridge-Smith of the University of Edinburgh have formed a company, Deurion LLC, to further develop and make commercially available the Surface Acoustic Wave Nebulization (SAWN) method of mass spectrometry. The Goodlett Lab developed this technology in 2011. In December, Deurion received a $150,000 National Science Foundation grant to continue its work. This grant built on a UW C4C Gap Fund of $50,000 that Goodlett received last summer to construct a prototype SAWN device. Washington Pharmacy 13
  • 11. School NewsAssistant Professor of Pharmaceutics Nina Isoherranen has been elected Meeting. The project was also named one of the top 50 student-submit-Secretary/Treasurer of the Drug Metabolism Division of the American ted abstracts for the meeting. She will receive a travel stipend from AGSSociety for Pharmacology and Experimental Therapeutics. to attend the meeting. In addition, this same project was accepted asAssociate Dean Nanci Murphy and pharmacy student Denise Ngo, ’14, a podium presentation at the 2012 Southern Pharmacy Administrationreceived a Project CHANCE award from the American Pharmacists As- Conference and the Western Pharmacoeconomic Conference.sociation-Academy of Student Pharmacists (APhA-ASP). They acceptedthe award from APhA-ASP and the Pharmacy Services Support Centerof the Health Resources and Services Administration in March in NewOrleans. This award will help fund an interprofessional student outreachproject at Community Health Care in Lakewood. Hollywood GlamourPharmacy Student News:The UW student chapter of the American Pharmacists Association(APhA)-Academy of Student Pharmacists won the Chapter of the YearAward in the AAA division at the APhA convention in New Orleans. Thegroup was honored for their community outreach to tribes, legislativeadvocacy and international health programs, among other activities.Elise Fields, ‘12, recently returned from an advanced pharmacy practiceexperience rotation in Windhoek, Namibia, where the UW has a stronginstitutional relationship with University of Namibia, the Ministry ofHealth and Social Services’ Therapeutics Information and Pharmaco-vigilance Centre, and Management Sciences for Health-Namibia. Forthis experience, Fields received a UW Thomas Francis, Jr. Global HealthFellowship Award.Kathy Glem, ’13, Cate Lockhart, ’13, Tahlia Luedtke, ’14, and Anne Spen-gler, ’13 won the UW Pharmacy and Therapeutics Competition.Denise Ngo, 14, received a scholarship from the National Associationof Chain Drug Stores Foundation for her work supporting continuing 2012 UPPOW Auctioneducation programs that focus on patient-centered care in communitypharmacies.Blaze Paracuelles, 14, received a UW Medical Center Martin Luther KingJr. Community Service Award. Friday, April 13, 2012Grad Student News: 7:00-11:00 pmPORPP student Carrie Bennette received a scholarship from the Ameri- University of Washington’s Kane Hallcan Society of Health Economists to attend the ASHE conference inMinneapolis in June. Walker-Ames RoomVeena Shankaran, a student in the Pharmaceutical Outcomes Research Tickets: $15& Policy Program (PORPP), has received the PORPP Endowed Prize inHealth Economics and Policy. This award recognizes her research on therisk factors for financial hardship in colon cancer patients. Please support professional development of student pharmacists with your attendance or tax-deductiblePharmaceutics graduate students Diana Shuster and Jenna Voellinger donation.each received an Institute of Translational Health Sciences (ITHS)TL1 Multidisciplinary Predoctoral Clinical Research Training award of$21,600 for the upcoming academic year. The ITHS TL1 program spon- Contact: Kristine Kim (kkim44@gmail.com)sors a year-long intensive clinical/translational research experience forpredoctoral students to conduct an original research project.PORPP student Heidi Wirtz’s project entitled, "Anticholinergic Medica-tion Use, Falls and Fracture in Postmenopausal Women: Results from theWomens Health Initiative" was accepted for an oral podium presenta-tion at the 2012 American Geriatrics Society (AGS) Annual Scientific14 Washington Pharmacy Washington Pharmacy 14
  • 12. Sid NelsonUW Mourns One of Their OwnContributed by UW School of Pharmacy Dean Thomas Baillie Toxicology from the Society of Toxicology, to name a few. Nor is it just about the deep love he had for this School of Pharmacy, his colleagues and our students. Sid was a constant presence at student events, alumni events and industry events over the years. He was an enthusiastic supporter of the people around him — cheer- ing loudly in the audience (along with his wife, Joan) at academic and industry events when our pharmacy students received awards; proudly supporting his Ph.D. students at scientific conferences around the world; regularly nominating his colleagues for prominent scien- tific honors; sending personal notes to alumni and former classmates when he heard exciting updates about their lives; and giving gener- ously to the School of Pharmacy in the form of scholarships and a fund he and his wife created. Indeed, there are just too many good things to say about Sid to encap- sulate what he meant to all of us. I suppose, when it comes down to it, what we will all miss about him most was his kind spirit. Sid Nelson was a caring, genuine man who made a positive impression on every- one who had the good fortune to know him. The School of Pharmacy is not going to be the same without him. We will all remember his off-color sense of humor, his giant collection of penguin paraphernalia and his enduring authenticity. Sid himself was an alumnus of the University of Washington School of Pharmacy, graduating in 1968 with a B.S. in pharmacy. He went on to receive a Ph.D. degree in medicinal chemistry from the University of California, San Francisco. He joined the UW School of Pharmacy faculty in 1977. He was dean of our School from 1994 to 2008. Under his leadership, the School converted from a B.S. degree to an entry-level Doctor of Pharmacy degree program and added a nontraditional approach that enabled existing pharmacists to obtain the Pharm.D. degree. He also evolved the graduate programs and worked tirelessly to expand "Students and colleagues of Sid Nelson will recall the large collection of pen- the School’s faculty. In 2008, he returned full time to his research and guin paraphernalia in his office. Over the years, he amassed this collection — teaching activities in the School’s Department of Medicinal Chemis- many of the items were gifts — after he made a stuffed penguin the unofficial try. In recent years, Sid held an NIH fellowship to conduct research in mascot of his lab." metabolomics/metabonomics at Imperial College London and he was I named a National University of Singapore distinguished professor. t is with profound sadness that the UW School of Pharmacy an- nounces that Professor of Medicinal Chemistry and Dean Emeritus On a personal note, I had known Sid for some 35 years, having first met Sidney “Sid” Nelson passed away suddenly on Friday, December him at a scientific conference in Europe while he was a fellow at NIH 9th. He was 66 years old. and I was a young faculty member at the University of London. We be- came good friends and kept in close contact over the years, eventually It is hard to put into words the impact that Dr. Sid Nelson had on this working together as faculty colleagues in the Department of Medicinal School, the University, the scientific community and everyone who Chemistry at the UW in the 1980s through 1990s. When I returned to knew him. the School of Pharmacy in 2008 to take over as dean, I knew I had big shoes to fill, but I also knew that he had left me a remarkable institu- It’s not just about the awards and honors Sid received for his leader- tion that he had played a major role in building — with an exceptional ship, his teaching and his prolific research — and there were many: community of faculty, staff, students and alumni. Dean of the Year from the American Pharmacists Association – Acade- my of Student Pharmacists, American Association of Colleges of Phar- His death is a major loss to our School, the University of Washington, macy Volwiler Research Achievement Award, UW Gibaldi Excellence academic pharmacy nationally, and the global scientific community. in Teaching Award, UW School of Pharmacy Distinguished Alumnus It was an honor to know him as an educator, mentor, colleague and Award, John J. Abel Award from the American Society of Pharmacol- friend. ogy and Experimental Therapeutics, and the Frank R. Blood Award in Washington Pharmacy 15
  • 13. Grow your business, secure your future Why have nearly 2,900 independent pharmacies joined Health Mart? Because only Health Mart provides the managed care representation, branding, in-store programs, specialized Diabetes Life Center, national and local advertising support, and collective strength you need to: • Attract new customers • Maximize your relationships with existing customers • Enhance business efficiency WASHINGTON HEALTH MART LOCATIONS: Aberdeen DuPont Medical Lake St. John Aberdeen Health Mart DuPont Health Mart Medical Lake Owl Health Mart St. John Health Mart Bellevue Duvall Moses Lake Seattle Pharmacy Plus Health Mart Duvall Family Health Mart Southgate Pharmacy Health Mart Luke’s Health Mart TLC Integrative Health Mart East Wenatchee Newport Meridian Health Mart Eastmont Health Mart Seeber’s Drug Health Mart Brewster White Center Health Mart Brewster Health Mart Ellensburg Nine Mile Falls Downtown Health Mart Lake Spokane Health Mart Spokane Bridgeport Hart & Dilatush Health Mart Gross Drug Health Mart Elma Odessa Lidgerwood Owl Health Mart Elma Health Mart Odessa Drugs Health Mart Cashmere Spokane Valley Doanes Valley Health Mart Fairfield Olympia Halpin’s Health Mart Fairfield Owl Health Mart Medical Center Health Mart Cheney Tonasket Cheney Owl Health Mart Freeland Yauger Park Health Mart Roy’s Health Mart Lind’s Health Mart ©2011 Health Mart Systems Inc. All rights reserved. RTL-05726-12-11 Chewelah Port Angeles Twisp Valley Drug Health Mart Hoquiam Jim’s Health Mart Ulrich’s Valley Health Mart Crown Drug Health Mart Cle Elum Quincy Wenatchee Cle Elum Health Mart Kenmore Heartland Health Mart Wenatchee Clinic Health Mart Ostrom’s Drugs Health Mart Colfax Republic Woodinville Tick Klock Drug Health Mart Kettle Falls Republic Drug Store Health Woodinville Health Mart Kettle Falls Health Mart Mart Coupeville Yakima Lind’s Health Mart Leavenworth Richland Terrace Heights Health Mart Village Health Mart Malley’s Health Mart Davenport Tieton Village Health Mart Lincoln County Health Mart Join Health Mart today! 855.HLTH.MRT | www.healthmart.com16 Washington Pharmacy
  • 14. Health Information Exchange (HIE)Q&A on HIE • Business based – satisfying a key business or grant requirement What are your key interests in Health The key question Sue Merk and Susan Boyer will be exploring is what Information Exchange (HIE)? are the highest priority communities of interest for Pharmacy with the HIE? Some possibilities might be: T he collaboration between the Washington State Pharmacy Association (WSPA) and OneHealthPort is entering a new • Using a common referral management form to share information phase. Over the past year Sue Merk, WSPA member, Senior with physicians about adverse drug reactions or patient Vice President at OneHealthPort and the person leading the compliance. statewide HIE effort has spoken in a number of WSPA venues. She has described the early stages of the HIE and • Connecting groups of local pharmacists shared some initial thoughts about how the with their local physician trading partners HIE can benefit Pharmacists. Sue’s experience to do eprescribing without those expensive and the tremendous feedback she received transaction fees have convinced OneHealthPort of the need to explore the HIE issue in greater depth with the Learning more about these ideas and most Pharmacy Community. importantly filling in that last blank with new ideas is what Susan Boyer’s engagement for OneHealthPort and WSPA discussed a variety OneHealthPort is all about. OneHealthPort of approaches to gather information with an wants to understand: eye toward tailoring an HIE offering specifically to Pharmacy. Ultimately, both groups decided • How current arrangements with what was needed was more than a survey, what was needed was a SureScripts and others are working or not? conversation. To facilitate this conversation, OneHealthPort was very pleased to discover just the right person at just the right time. At • What Pharmacy information exchange needs are currently being the end of March, Susan Boyer will complete her work as Executive met, where? Director of the Washington State Board of Pharmacy and become an independent consultant. OneHealthPort has secured Susan’s services • What urgent information exchange needs are not being to lead a conversation with the Pharmacy Community about the HIE addressed with current solutions? opportunity. The HIE is a flexible, low-cost exchange service. This is your chance to As OneHealthPort has worked to deploy the HIE in Washington create a community of interest around your exchange needs, with your state, it has gained a number of insights. One key insight has been key trading partners and solve your pressing problems. the emergence of “Communities of Interest.” By definition HIE is an “exchange,” it is not a solitary activity within a single enterprise, it is Susan will begin her work on OneHealhPort’s behalf in mid-April. At at least two and often multiple organizations that come together that time she’ll be reaching out to the Pharmacy Community. In the around a specific information need. These organizations share a interim you can check out the latest news about the HIE at: common interest in electronic health information exchange and so form a “community.” The interests can be: http://www.onehealthport.com/HIE/index.php • Geographical – health care organizations located near each OneHealthPort and WSPA are both looking forward to the upcoming other that want to form a local network conversation beginning in April. • Transactional – different enterprises that want to exchange a specific data set Washington Pharmacy 17
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  • 18. continuing education for pharmacists Volume XXX, No. 2Restless Legs Syndrome and ManagementThomas A. Gossel, R.Ph., Ph.D., Professor Emeritus, Ohio Northern University, Ada, Ohio andJ. Richard Wuest, R.Ph., PharmD, Professor Emeritus, University of Cincinnati, Cincinnati, OhioDr. Thomas A. Gossel and Dr. J. Richard to tolerate sedentary activities canWuest have no relevant financial relation- lead to a compromised ability toships to disclose. enjoy life, and serious problems maintaining relationships. RLS hardly receives the atten-Goal. The goal of this lesson is tion it deserves. It has attracted lit-to review restless legs syndrome, tle attention in medical textbookswith emphasis on presenting key until recently. A study conductedpoints of information to pass along jointly in the United States andto patients. Gossel Wuest Europe suggests that the condi- tion is not only under-reported,Objectives. At the completion of the United States may experience but also greatly under-diagnosedthis activity, the participant will be RLS symptoms, although the exact and under-treated. A 1996 reportable to: prevalence may be much higher described the outcome of a group 1. demonstrate knowledge of because it is generally held that of patients who delayed seekingrestless legs syndrome including its many patients fail to discuss their medical help for many years, butcauses and triggers, epidemiology symptoms with healthcare provid- even after they did receive help, ac-and prevalence, pathogenesis, and ers. Patients may believe their curate diagnosis frequently took aclinical impressions; condition is too insignificant with decade or more. The Restless Legs 2. explain the mechanism of which to bother their physician, or Syndrome Foundation has takenaction and major adverse events they may not recognize that RLS account of these observations andassociated with the drugs used in can be symptomatic of more serious often reminds its constituency thattreating restless legs syndrome; pathology that requires physician RLS is “the most common disorder 3. select nonpharmacologic intervention. A sensorimotor (both you have never heard of!”measures that are reported to sensory and motor) neurologic This lesson describes RLS,modify symptoms of restless legs movement disorder, RLS causes including its clinical features andsyndrome; and patients to experience an almost medical management. It stresses 4. demonstrate an understand- irresistible urge to move their legs. information that will be useful noting of information relative to Usually worse during periods of only to pharmacists, but also torestless legs syndrome to convey to inactivity or rest, walking or other patients who experience the condi-patients and their caregivers. physical activity involving the legs tion. can usually alleviate the sensa-Background tions. Often associated with a sleep Epidemiology andRestless legs syndrome (RLS), complaint, the inability to rest Prevalencealso known as Ekbon’s syndrome, can have a negative impact on the RLS can affect persons of any racewas named after Swedish neurolo- patient’s quality of life due to agita- or ethnic group, but it is more com-gist/physician Karl Ekbon. In the tion, discomfort, frequent wak- mon in persons of Northern Euro-mid-1940s, Ekbon described the ing, chronic sleep deprivation and pean descent. African Americanscondition as a common and dis- stress. These conditions, in turn, are affected significantly less oftentressing condition, but one that is can negatively affect job perfor- than Caucasians. Its prevalence isreadily treatable. Two to 15 per- mance, social activities, and family distinctly lower in Asian popula-cent of the general population of life. Disturbed sleep and inability tions, ranging from 0.1 percent in Washington Pharmacy 21
  • 19. Etiology and when attempting to control symp- Table 1 Pathophysiology toms. Drugs reported to Although RLS is a disorder of the Secondary Causes. A number exacerbate RLS central nervous system, it is not a of secondary causes of RLS have psychophysiologic pathology; how- been identified. For example, symp- • Alcohol toms of RLS may be associated • Analgesics (NSAIDs, non-opioid) ever, it may contribute to or be ex- acerbated by such conditions. RLS with iron deficiency. A patient’s • Anesthetics (bupivacaine, can generally be categorized into iron stores may be deficient with- mepivacaine) • Anticonvulsants (methsuximide, primary (idiopathic) and secondary out causing anemia. Studies have phenytoin, topiramate, zonisamide) forms. Primary RLS is not related shown that decreased iron stores • Antidepressants (mirtazapine, to other identifiable abnormalities; (i.e., ferritin levels below 50 µg/L) SSRIs, trazodone, tricyclics, secondary RLS is associated with can exacerbate RLS symptoms. venlafaxine) an underlying pathology. When Iron is an essential cofactor for • Antihistamines (older) tyrosine hydroxylase, the rate-lim- no specific cause can be identified • Antipsychotics (clozapine, iting enzyme for dopamine synthe- olanzapine, quetiapine, for initiating RLS symptoms, it is considered a primary condition. sis. Animal studies demonstrate risperidone) It is thought that RLS may be that iron deficiency is associated • Beta-adrenergic blockers (pindolol) • Caffeine due to dysfunction of dopamine- with hypofunction of dopamine D2 • Donepezil producing cells in the nigrostriatal receptors that is corrected by iron • Interferon-alfa/ pegylated areas of the brain. Pharmacologic replacement. The fact that the interferon-alfa studies have shown a dramatic extent of iron deficiency correlates • Levothyroxine improvement in RLS symptoms well with symptoms and that iron • Lithium is an effective therapy, at least with administration of levodopa, • Methadone (withdrawal) in iron-deficient patients, provide • Metoclopramide the precursor of dopamine, or with dopaminergic agonists that act on strong support for the role of iron • Nicotine dopamine receptors in the brain. deficiency in the pathogenesis of • Sodium oxybate Conversely, dopamine antagonists some patients with RLS. Physi- will worsen symptoms in patients cians often order serum ferritin with RLS. Advanced brain imaging levels in patients with newly diag-Singapore to 4.6 percent in elderly has revealed decreased dopamine nosed RLS or RLS patients with aJapanese. Epidemiological studies D2 receptor binding in the striatum recent exacerbation of symptoms.in the general population of the of patients with RLS. Hypoactive Once iron levels are corrected (dis-United States and Europe show dopaminergic neurotransmission cussed subsequently), symptomswidely different prevalence rates, in RLS has recently been demon- are reduced.probably related to the variety of strated and study results suggest RLS has been reported in per-experimental design. Prevalence that both striatal and extrastriatal sons with spinal cord and periph-of RLS among patients in primary brain regions are involved. eral nerve lesions, and in patientscare settings has also been esti- The high incidence (40 to 60 with vertebral disc disease. Themated. Results from a large survey percent) of familial cases of RLS exact pathological mechanismof primary care centers in Europe strongly suggests a genetic origin remains unknown.and the United States reported for primary RLS, especially if the RLS occurs in up to one-half ofthat overall, 11.1 percent of pa- condition onsets at an early age. patients with end-stage renal fail-tients experienced any degree of Family and twin studies have ure. Symptoms may be especiallyRLS symptoms, while 9.6 percent proposed both autosomal-dominant bothersome during dialysis whenreported symptoms at least once as well as recessive modes of in- the patient is in a forced restingweekly. heritance. Genetic studies suggest position. Improvement in RLS RLS has a variable age of onset several chromosomal loci associ- symptoms has been shown afterwith prevalence increasing with ated with RLS. At present, five renal transplantation.advancing age. It can also occur in loci have been mapped for RLS in One in five women experi-children. Studies confirm that in single families, and three suscep- ence symptoms during pregnancy,patients with severe RLS, one- tibility loci have been identified in especially in their last trimester.third to two-fifths experienced their a genome-wide association study. Some women, in fact, report RLSfirst symptoms before age 20 years, Secondary causes of RLS are more for the first time during pregnancy.although a precise diagnosis of RLS common in persons who develop Symptoms can be severe, but usu-was made much later. Women are symptoms for the first time in later ally subside within four weekstwice as likely as men to develop life; secondary RLS occurs in over postpartum.RLS. 70 percent of persons with onset at RLS symptoms may be wors- age 65 years or more. It is impor- ened or unmasked by a variety of tant to rule out secondary RLS medications (Table 1). As a group,22 Washington Pharmacy
  • 20. lower legs (calves); however the Table 2 aggravating sensations may also Table 3 Terms patients may use occur any place in the legs or feet. Criteria for diagnosis when describing They may also occur in the arms of RLS RLS symptoms or elsewhere. The feelings seem Diagnostic criteria* Aching Flowing water to originate from deep within the •Compelling urge to move the limbs, Burning Numb limbs, rather than from the joints, usually associated with paresthesias/ Buzzing Painful or on the surface. The sensations dysesthesias Cramping Pulling are usually bilateral, but may oc- •Motor restlessness as noted in Crawling Restless cur in one leg, move from one leg activities such as floor pacing and Creeping Searing to the other, or affect one leg more rubbing the legs Drawing Tense than the other. The pain is more of •Symptoms present or worse during Electric current-like Tingling rest, with temporary relief by activi- an ache rather than sharp, jab- Gnawing Tugging ties such as walking or stretching, at bing pain. Symptoms are generally least as long as the activity continues Indescribable Uncomfortable Itching worse in the evening and night, •Symptoms worse in evening and at Feeling of worms or bugs crawling and less severe in the morning. night than during the day, or occur under my skin Symptoms appear with rest, sitting only in the evening or night or lying down. The more comfort- able the patient is, the more likely Supportive clinical features±antidepressants are the drugs most it is that RLS symptoms will occur. •Sleep disturbance and daytimecommonly implicated in secondary The reverse is also true – the less fatigueRLS with almost all classes report- comfortable the patient is, the less •Normal neurological examination ined to worsen symptoms. Persons primary RLS likely it is that symptoms will on- •Involuntary, repetitive, periodic,with RLS who take one or more set. As a result, some patients mayof the listed drugs are advised to jerking limb movements during sleep prefer to sleep on a hard surface or while awakediscuss with their physician the including the floor rather than in •Positive family history of RLSpossibility of changing medications a comfortable bed. The condition •Positive response to dopaminergicto improve symptoms. should be distinguished from sleep- therapy related disorders of the legs.Clinical Assessment Periodic Limb Movements Associated features§A diagnosis of RLS is based pri- in Sleep. The presence of repeti- •Natural clinical course: Onset agemarily on a careful patient history is variable, in patients with earlier tive and highly stereotypic periodic onset (<50 years) the symptoms areand detailed physical and neuro- limb movements in sleep (PLMS)logical examination. There is no insidious, while patients with later supports, but does not confirm, a onset have a more aggressive course.laboratory test that can affirm the diagnosis of RLS. PLMS is also RLS is usually a chronic disease withpresence of RLS. The patient’s known as periodic limb move- a progressive clinical course; in thephysical examination is often ments and periodic limb movement mildest forms of RLS, the clinicalnormal, except for those who have disorder, and was formerly referred course can be static or intermittent.symptomatology suggestive of a to as myoclonus. PLMS is noted as •Sleep disturbances: disturbed sleepsecondary form of RLS or a comor- repetitive movements, typically in is usually associated with RLS.bid condition. •Medical evaluation/Physical exami- the lower limbs, that occur every nation: physical and neurological ex- Symptoms may be described by 20 to 40 seconds. Symptoms canpatients as ranging from mild to amination is generally normal (except also occur in the arms. Hundreds for secondary RLS). Medical evalua-intolerable. Due to the subjective of these involuntary, rhythmic tion should be addressed to identifynature of the disorder, however, muscular jerks in the lower limbs possible causes for secondary RLS.patients often experience difficulty may occur, sometimes throughoutin describing their symptoms. the night. Affected persons areOftentimes their sensation defies often not aware they are experienc- *Minimal criteria for positive diagnosisdescription (Table 2). Confirmation of RLS ing the movements. In a person ±Supportive clinical features common inof RLS is not easy. A population with severe RLS, these involuntary RLS but not required for diagnosisstudy showed that a large number kicking movements may also occur §These features may provide additionalof patients do not seek medical aid while awake. PLMS is common in information about the patient’s diagnosisbecause of their motor condition, older adults, even those withoutbut rather because of the conse- RLS, and doesn’t always disrupt Essential Criteria that Con-quences of their disorder such as sleep. Eighty percent of persons firm RLS. The International Rest-insomnia or decreased quality of with RLS also experience PLMS, less Legs Syndrome Study Grouplife. which correlates with RLS sever- in collaboration with the National Most patients with RLS ex- ity, but less than half of those with Institutes of Health has estab-perience the feelings in their PLMS also have RLS. lished criteria for diagnosis of RLS Washington Pharmacy 23
  • 21. (Table 3). Four essential criteria such as deep vein thrombosis can and indeed, there are no FDA-must be present to establish a posi- be confused with RLS. approved drugs for use in childrentive diagnosis. A mnemonic to help with RLS. Case histories andremember these points is URGE: RLS in Children anecdotal reports suggest it is bestUrge to move, Rest induced, Gets Although RLS is generally dis- to begin with good sleep hygienebetter with activity, Evening and cussed as a disease of adults, over measures, cognitive behavioralnight accentuation. In the absence the past 20 years there has been therapy and caffeine restrictionof the core clinical features of RLS, increasing recognition that it also (including restriction of caffeinateda positive diagnosis of RLS cannot occurs in children. Adults with soft drinks). If these measures arebe made, and other causes of PLMS the diagnosis often retrospectively ineffective, screening for anemiaor isolated periodic limb movement recall having had symptoms during and checking the patient’s serumdisorder must be considered. The their childhood. Case series have ferritin level makes sense. Forrelation between PLMS and RLS described children as young as children, elemental iron in doses ofis unclear, but treatments used for 18 months of age with features of 3 mg/kg/day given for three monthsRLS may also be effective in PLMS RLS. was shown to improve PLMS andas well. The presence of supportive Diagnosing RLS in children is clinical symptoms, but more dataand associated clinical features as particularly difficult because clini- are needed to determine effective-shown in Table 3 is not necessary cians rely heavily on the patient’s ness in pediatric RLS. Dopaminer-for a positive diagnosis, but they description of symptoms. Even for gic drugs used “off-label” in chil-are definitely helpful to the differ- adults with RLS, an accurate de- dren have been shown to improveential diagnosis. scription of its subjective symptoms RLS symptoms. In cases of associ- Differential Diagnosis. RLS may be difficult. Children may ated ADHD, dopaminergics mayshould be differentiated from other describe RLS symptoms differently benefit ADHD symptoms as well.conditions including: than adults, using terms such as •Nocturnal Leg Cramps. These oowies, ouchies, tickle, spiders, Treatment in Adultstypically include painful, palpable, twitchy, jerky, boo-boos, want to There is no cure for primary RLS.involuntary muscle contractions, run, and a lot of energy in my legs. Both nonpharmacologic measuresoften focal, with a sudden onset. Or, children may have at least two and pharmacotherapy, however,Nocturnal leg cramps are usually of the following: sleep disturbance, are helpful in relieving symptomsunilateral. a biological parent or sibling with in many patients. It is important •Akathisia. This is a closely re- RLS, or polysomnographic-docu- to note that both severity andlated disorder, described as a condi- mented PLMS. Determining RLS frequency of RLS are variable;tion of motor restlessness, ranging in children can be aided using the therefore, nonpharmacologic thera-from a sense of inner disquiet, to same four criteria as for adults (see pies alone may be appropriate forinability to sit or lie quietly or to Table 3). milder forms of RLS and indeed,sleep, with no sensory complaints. According to a recent survey these measures should be consid-The restlessness is generalized and of more than 10,000 families in ered first in all but the most severeinternal rather than localized to the United States and the United cases. It is also important to notethe limbs and associated with par- Kingdom, RLS affects about 2 that many pharmacologic agentsesthesias. Akathisia often does not percent of children. A pediatric are used in an “off-label” basis.correlate with rest or time of day, RLS prevalence of 5.9 percent was Successful treatment for secondaryand often results as a side effect of noted at one pediatric sleep disor- RLS requires treating the underly-medication such as neuroleptics or ders clinic. Another study found ing cause. Goals of treatment areother dopamine blocking agents. a prevalence of 1.3 percent in 12 to prevent or relieve symptoms, •Peripheral Neuropathy. This pediatric practices, and another re- increase the amount and improvecan cause leg symptoms that are ported its occurrence in 6.1 percent the quality of sleep, and treat ordifferent from RLS. Symptoms are of Canadian children ages 11 to 13 correct any underlying conditionusually neither associated with years. The U.S./U.K. study found a that may trigger or worsen RLS.motor restlessness nor lessened strong genetic component to RLS. Lifestyle and Behavioralby movement. The condition is not More than 70 percent of children Changes. For those with mild-to-worse during the evening or night- with RLS had at least one parent moderate symptoms, preventiontime. Sensory complaints include with the condition. There is also is key to their control. In gen-numbness, tingling or pain. Small evidence suggesting that children eral, simple lifestyle changes thatfiber sensory neuropathies such as with attention deficit hyperactiv- promote good health can play anthose seen in diabetes mellitus may ity disorder (ADHD) and a family important role in alleviating symp-be confused with RLS. Patients history of RLS are at risk for more toms of RLS. The measures listedwith neuropathies may have both severe ADHD. in Table 4 may help reduce theneuropathic and RLS symptoms. Most children with RLS do not discomfort and excessive leg move- •Vascular Disease. Conditions require pharmacologic treatment ments. The websites listed in Table24 Washington Pharmacy
  • 22. patients. Treatment must there- Table 4 fore be individualized. Selection of Table 5 Nonpharmacologic pharmacologic agents is influenced Support groups for RLS management of RLS by a number of factors, including: •Restless Legs Syndrome Foundation •Patient Age. Benzodiazepines, www.rls.org •Identify any underlying disorders and treat, if feasible for example, may cause cognitive •Eliminate precipitants of RLS impairment in elderly patients. •Worldwide Education and Aware- -Drugs (see Table 1) •Symptom Severity. Patients ness for Movement Disorders -Common stimulants and depres- with mild symptoms may elect to (WE MOVE) sants: caffeine, alcohol, nicotine forgo using medications due to cost, www.wemove.org •Practice good sleep hygiene adverse effects or other reasons. -Establish regular sleep and wake •National Sleep Foundation Others may benefit from a dop- times www.sleepfoundation.org aminergic agent or a dopamine -Restrict bed to sleep and intima- agonist. Severe symptoms may •National Institute of Neurological cy; remove TV, stereo -Avoid perturbing activities im- require a strong opioid. Disorders and Stroke (NINDS) mediately before sleep •Symptom Frequency. Persons www.ninds.nih.gov/disorders/ -Avoid bright lights in late evening with infrequent symptoms may restless_legs/restless_legs.htm or night benefit greatly from a single dose of -Have a light snack before bedtime medication given on an as-needed •National Heart, Lung and Blood •Apply simple behavioral basis, such as an opioid or levodo- Institute (NHLBI) interventions www.nhlbi.nih.gov/health/dci/ pa. -Brief walk before bedtime Diseases/rls/rls.htm •Pregnancy. Neither safety -Hot bath or cold shower nor efficacy of medications for RLS -Massage limbs -Practice meditation and/or yoga has been assessed in clinical trials a while, patients start to awaken -Avoid heavy meals within 3 hours involving pregnant women. early in the morning with recur- of bedtime •Renal Failure. Most pharma- rence of their RLS. Sustained-re- -Avoid excessive napping during cologic agents are generally safe in lease formulations can delay onset daytime patients with renal failure, al- of rebound until later in the morn- •Moderate exercise: neither inactivi- though dose frequency and quanti- ing, although the long-term efficacy ty nor unusual and excessive exercise ty may be modified if the drugs are of this approach remains unknown. •Weight management: healthy diet excreted via the kidney. Moreover, Augmentation is more serious. and adequate activity for dialysis patients, some medica- It may shorten symptom-free •Information and support: use web- sites and patient support groups (see tions are dialyzable (e.g., gabapen- periods at rest. Also, symptoms Table 5) tin) while others are not. develop earlier in the day (morn- Dopaminergic Agents. ing or afternoon instead of evening Discovery that levodopa was ef- or night) and may become more5 provide valuable information that fective in RLS revolutionized its severe; and symptoms may developcan be passed along to patients. management. Every dopaminergic in parts of the body that were not Pharmacologic. Although agent tested has been shown to be previously involved. Augmenta-nonpharmacologic strategies may effective against RLS and PLMS. tion occurs in up to 80 percent ofwork for some patients with milder Levodopa/carbidopa (Sinemet®, and patients treated with levodopa assymptoms, most individuals with others) provides near-immediate early as four weeks into treatment.mild-to-moderate symptoms will relief from RLS. The response is so Approximately one-third haverequire medication to help make characteristic that a brief course sufficiently severe symptoms thatsymptoms tolerable. Medical of therapy may be considered in warrant a change in therapy. Themanagement of RLS is a rap- patients whose diagnosis of RLS is precise mechanisms contributingidly developing field. Large-scale in doubt. Levodopa is also effec- to augmentation are unknown. Themulticenter trials in RLS became tive in hemodialysis patients with need for higher doses of levodopacommon only since the beginning of RLS. In general, the drug is very and development of more severethe 21st century. To date, only three well tolerated. Levodopa-induced RLS may predict developmentdrugs have earned FDA approval dyskinesias have not been reported of this complication. Levodopafor RLS: ropinirole (Requip®) in in RLS patients. is, therefore, no longer the treat-May 2005, pramipexole (Mirapex®) Two troublesome and common ment of choice for RLS, althoughin November 2006 and gabapentin problems develop with prolonged it remains a therapy of choice forenacarbil (Horizant™) in April use of levodopa, which limits the persons with only intermittently2011. Since symptom severity var- value of this otherwise almost ideal severe symptoms.ies greatly between patients, no agent for RLS: rebound and aug- Dopamine Receptor Ago-single medication or combination of mentation. Rebound is an outcome nists. These are now regarded asdrugs will work predictably for all of the drug’s short half-life; after the first-line treatment for RLS. Washington Pharmacy 25
  • 23. The non-ergot agonists ropinirole ated in older patients; however, its is 325 mg ferrous sulfate threeand pramipexole have been shown long duration of action may result times daily along with 100 to 200to benefit RLS in randomized con- in more adverse effects, such as mg vitamin C with each dose totrolled trials. There is no indication an unsteadiness leading to falls enhance absorption. Oral iron canbased on the numerous compara- during the night and drowsiness or cause constipation and abdominaltive clinical trials reported for the cognitive impairment in the morn- discomfort, and the dose may needdopamine receptor agonists that ing. to be reduced in some patients.efficacy of one agent is better than Antiepileptics including Oral iron should ideally be takenanother. The drugs are chemically carbamazepine (Tegretol®, and oth- on an empty stomach to enhancedistinct from dopamine, but their ers) and gabapentin (Neurontin®, absorption. If gastrointestinalmechanism of action in the central and others), have been reported to symptoms develop, it should benervous system is similar to that of be efficacious in treating RLS, but taken with food. Follow-up ferri-the endogenous neurotransmitter. are not commonly used in clinical tin determinations are indicated, Studies suggest that the drugs practice due to their high incidence initially after three to four monthsare well tolerated in patients with of adverse effects. Antiepileptics and then every three to six monthssevere RLS who have failed other may be effective in patients with until the serum ferritin level istherapies and in those with aug- RLS who also suffer from painful greater than 50 µg/L. Iron therapymentation. Augmentation and paresthesias or underlying neur- can then be discontinued. Fortolerance have been reported, opathy. The most recently ap- patients with severe iron deficiencyalthough at a much lower inci- proved drug for RLS, gabapentin (ferritin ≤10 µg/L) and oral irondence than seen with levodopa, and enacarbil (Horizant™) is a prodrug intolerance, intravenously admin-they seem more likely to occur in of gabapentin and accordingly, its istered iron can be considered. Ofpatients who previously developed therapeutic effects in RLS are at- note is that RLS does not alwayssimilar problems with levodopa. tributable to gabapentin. respond to an increasing serum fer-Dose reduction may be required if The management of RLS ritin concentration, even if it wasaugmentation or tolerance develop, continues to evolve as new drugs low initially.but, unlike with levodopa, a change become available. Cabergolinein medication is rarely needed. (Dostinex®, and others), a dop- PrognosisSeveral reports of unusual compul- amine agonist, is of interest be- RLS is usually a lifelong condi-sive behaviors occurring in persons cause of its long half-life (65 hours). tion that has no cure. Although ittaking dopamine receptor agonists This theoretically might produce has a variable course, symptomsinclude pathological gambling and less augmentation. Magnesium has may gradually worsen with age,increased sexuality. been reported in a small open-label albeit more slowly for those with Other Medications. The trial to be an effective therapy for the primary form of RLS thantherapeutic effect of opioids is RLS. for patients who also suffer fromwell known. Intermittent use of Selecting the Best Treat- an associated medical condition.low-potency opioids or opioid recep- ment for a Particular Patient. Nonetheless, current therapies cantor agonists, usually taken before This usually proceeds in a “hit or control RLS, minimizing symptomsbedtime, can be effective. Studies miss” manner. Drugs should be and maximizing periods of restfulhave shown positive short-term used at their lowest effective dose, sleep. Some patients experienceand long-term responses of various and only when necessary should remissions, periods during whichopioids. In severe disease, opioids the dose be slowly titrated upward. symptoms decrease or disappearmay be considered a second-choice Medication should be taken early for days, weeks or months; how-treatment after dopaminergic enough to permit absorption and ever, symptoms usually reappear.agents. There is a chance for de- action before the onset of sleep. A diagnosis of RLS that onsets dur-pendence, and these drugs should Divided doses may be needed, often ing adulthood does not indicate thebe used with caution in persons provided with the evening meal onset of another neurologic disease.with a history of addiction. and later at night. If the first drug Individuals with RLS secondary to Benzodiazepines or benzo- does not work, then a second agent an underlying condition may notediazepine receptor agonists, with a different mode of action resolution of symptoms when theirtaken before sleep, may be use- should be substituted. Sometimes a underlying condition is treated.ful. This is especially relevant combination of medications works Medication, when needed, usuallyif the patient has another cause better than any single agent. provides relief of symptoms.of poor sleep in addition to RLS, Iron Replacement in Sec-such as psychophysiologic insom- ondary RLS. As noted earlier, a Summary and Conclusionsnia. Most data have been derived serum ferritin concentration below RLS is a common but under-recog-with clonazepam (Klonopin®, and 45 to 50 µg/L has been associated nized disorder associated with dis-others). Some investigators have with increased severity of RLS. comfort in the legs that is hard toshown this drug to be well toler- A common treatment regimen describe and a distressing urge to26 Washington Pharmacy
  • 24. move them. It increases in frequen-cy with aging, but is also found in NEW Requirement forchildren. Sleep disruption in RLSmay impact daytime functioningand quality of life. For patients CE Participants: CPE Monitorwith mild symptoms, no drug treat- Do you have your NABP eProfile ID number?ment may be necessary; nonphar-macologic measures may be all that CPE Monitor is a national, collaborative effort by NABP and the Accreditation Council foris needed. In patients with moder- Pharmacy Education (ACPE) to provide an electronic system for pharmacists and pharmacyate to severe, troublesome symp- technicians to track their completed continuing pharmacy education (CPE) credits. It willtoms, a dopamine receptor agonist also offer state boards of pharmacy the opportunity to electronically authenticate theis the current treatment of choice, CPE units completed by their licensees, rather than requiring pharmacists and techniciansalthough it should be noted that to submit their proof of completion statements upon request or for random audits. This initiative will streamline processes for pharmacy practitioners to ensure they are maintain-there have been few satisfactory ing professional competency requirements. CPE Monitor is expected to save pharmacists,studies comparing different phar- pharmacy technicians, state boards of pharmacy, and CPE providers time and money.macotherapies. If dopamine ago-nists are poorly tolerated or ineffec- Pharmacists and pharmacy technicians will receive a unique ID after setting up theirtive, levodopa may be a satisfactory e-Profile with NABP. As ACPE-accredited providers begin transitioning their systems tooption for many people, especially CPE Monitor throughout 2012, pharmacists and pharmacy technicians will need to beginfor those with intermittent symp- providing their NABP e-Profile ID and date of birth to the provider when they register fortoms, such as during a long trip or CPE or submit a request for credit. The system will then direct electronic data from ACPE-sitting through a boring lecture! It accredited providers to ACPE and then to NABP, ensuring that CPE credit is officially verified by the providers. Once information is received by NABP, pharmacists and pharmacy techni-takes only 15 to 30 minutes to be- cians will be able to log in to access information about their completed CPE activities. Aftercome effective, and augmentation a transition period, ACPE-accredited CPE providers will no longer be required to distributeis not a risk with intermittent use. statements of credit. In addition, boards of pharmacy will be able to request reports on their licensees, elimi- nating the need for pharmacists and technicians to send paper copies of CPE statements of credit. Instead, records kept in CPE Monitor will be sent to the boards for CPE activities taken from ACPE-accredited providers.The authors, the Ohio Pharmacists In Phase 2 of the CPE Monitor initiative, CPE Monitor will add a function to record CPE fromFoundation and the Ohio Pharmacists providers not accredited by ACPE in addition to CPE activities from ACPE-accredited provid-Association disclaim any liability to ers. Until Phase 2 is completed, pharmacists and technicians will need to submit proof ofyou or your patients resulting from completion of CPE from providers not accredited by ACPE directly to the board of phar-reliance solely upon the information macy when required to do so.contained herein. Bibliography for ad-ditional reading and inquiry is avail- To prepare for the new process, pharmacists and technicians are encouraged to obtainable upon request. their NABP e-Profile ID now to ensure their e-Profile is properly setup. Many ACPE-accredit- ed CPE providers are now requiring pharmacists and pharmacy technicians to submit theirThis lesson is a knowledge-based CE e-Profile ID and date of birth to receive credit for completed CPE.activity and is targeted to pharmacistsin all practice settings. To get you NABP e-Profile ID number, go to www.nabp.net. Once you obtain your NABP e-profile ID number, don’t forget to log in and update your WSPA profile at www.wsparx.org. Program 0129-0000-12-002-H01-P Release date: 2-15-12 Expiration date: 2-15-15 CE Hours: 1.5 (0.15 CEU)The Ohio Pharmacists Foundation Inc. isaccredited by the Accreditation Councilfor Pharmacy Education as a provider ofcontinuing pharmacy education. Washington Pharmacy 27
  • 25. continuing education quiz Please print. Program 0129-0000-12-002-H01-P 0.15 CEU Name________________________________________________Restless Legs Syndrome and Management1. Restless Legs Syndrome (RLS) is: Address_____________________________________________ a. a motor disorder. b. a sensory disorder. City, State, Zip______________________________________ c. both a motor and a sensory disorder. d. neither a motor nor a sensory disorder. Email_______________________________________________2. RLS is more common in which of the following groups NABP e-Profile ID*__________________________________ *Obtain NABP e-Profile number at www.MyCPEmonitor.net.of people? a. African Americans c. Asian Americans Birthdate____________ b. Northern Europeans d. Southern Europeans (MMDD) Return quiz and payment (check or money order) to3. RLS is NOT a psychophysiologic pathology. Correspondence Course, OPA, a. True b. False 2674 Federated Blvd, Columbus, OH 43235-49904. An essential cofactor for tyrosine hydroxylase, therate-limiting enzyme for dopamine synthesis, is: a. magnesium. c. calcium. b. iodine. d. iron. 9. Most children with RLS require pharmacologic treat- ment.5. The group of drugs most commonly implicated in a. True b. Falsesecondary RLS is the: a. antidepressants. c. antipsychotics. 10. All of the following are considered to be good sleep b. antiepileptics. d. antirheumatics. hygiene management EXCEPT: a. avoid bright lights in late evening or night.6. Diagnosis of RLS can be easily determined by a spe- b. establish regular sleep and wake times.cific laboratory test. c. avoid perturbing activities immediately before a. True b. False sleep. d. do not eat anything after the evening meal.7. Periodic limb movement disorder was formerly re-ferred to as: 11. All of the following drugs have been approved for a. dyskinesia. c. myoclonus. treating RLS EXCEPT: b. intermittent claudication. d. Raynaud’s disorder. a. gabapentin. c. quinine. b. pramipexole. d. ropinirole.8. The condition characterized by symptoms that areusually neither associated with motor restlessness nor 12. Which of the following drugs is dialyzable?lessened by movement is: a. Gabapentin c. Quinine a. akathisia. b. Pramipexole d. Ropinirole b. intermittent claudication. c. nocturnal cramps. 13. The troublesome and common problem that develops d. peripheral neuropathy. with prolonged use of levodopa that is more serious is: a. augmentation. b. rebound.Completely fill in the lettered box corresponding to 14. Which of the following is regarded as first-line treat-your answer. ment for RLS?1. [a] [b] [c] [d] 6. [a] [b] 11. [a] [b] [c] [d] a. Benzodiazepines2. [a] [b] [c] [d] 7. [a] [b] [c] [d] 12. [a] [b] [c] [d] b. Dopamine receptor agonists3. [a] [b] 8. [a] [b] [c] [d] 13. [a] [b] c. Dopaminergic agents4. [a] [b] [c] [d] 9. [a] [b] 14. [a] [b] [c] [d] d. Opioids5. [a] [b] [c] [d] 10. [a] [b] [c] [d] 15. [a] [b] [c] [d] I am enclosing $10 (member); $15 (nonmember) for 15. Most data on the use of benzodiazepines to treatthis month’s quiz made payable to: Ohio Pharmacists RLS have been derived with:Association. a. alprazolam. c. clonazepam.1. Rate this lesson: (Excellent) 5 4 3 2 1 (Poor) b. chlordiazepoxide. d. diazepam.2. Did it meet each of its objectives?  yes  no If no, list any unmet_______________________________3. Was the content balanced and without commercial bias?  yes  no4. Did the program meet your educational/practice needs?  yes  no To receive CE credit, your quiz must be postmarked no later than Feb- ruary 15, 2014. A passing grade of 80% must be attained. CE state-5. How long did it take you to read this lesson and complete the ments of credit are mailed February, April, June, August, October, and quiz? ________________ December until the CPE Monitor Program is fully operational. Send6. Comments/future topics welcome. inquiries to opa@ohiopharmacists.org.
  • 26. Endorsed by:**Guarantee a better Quality of Life for your family. Life Insurance can provide for your loved ones by: • Providing coverage for final medical and funeral expenses • Paying outstanding debts • Creating an estate for those you care about • Providing college fundingLife insurance solutions from The Pharmacists LifeInsurance Company. For more information, contact your local representative: Anne Kelley, AAI Kim Dornbier, CISR, CIC 800.247.5930 ext. 7147 800.247.5930 ext. 7441 425.501.1428 515.320.1214 www.phmic.com * * This is not a claims reporting site. You cannot electronically report a claim to us. To report a claim, call 800.247.5930. ** Compensated endorsement. Not all products available in every state. The Pharmacists Life is licensed in the District of Columbia and all states except AK, FL, HI, MA, ME, NH, NJ, NY and VT. Check with yourPO Box 370 • Algona Iowa 50511 representative or the company for details on coverages and carriers.
  • 27. Pharmacist Full or part-time for independent Compound- ing Pharmacy located in Long Beach, WA, a PCCA pharmacist Member. Tired of working Sundays, holidays, and late nights? If you are interested in having a life outside of work and working Must be licensed in the state of Washington . for a Northwest based and employee owned company that Possible partnership and to purchase. offers great schedules, excellent benefits, wages and working conditions, Bi-Mart is looking for you! We are seeking a staff Pharmacist for our Oregon locations in Lincoln City, Please reply with a cover letter and resume to: Hermiston, Winston, and Klamath Falls. Apply by calling 1-800-456-0681 ext. 308 or email: RxCareer@bimart.com. Shiela Weller PO Box 1078 Long Beach, WA 9863130 Washington Pharmacy
  • 28. Rx and The LawBy Don McGuire, R.Ph., J.D. RECORDKEEPING ISN’T THAT have become key points in a case. The lesson here is that no record is too small or too trivial to be skipped over. Update those inventory IMPORTANT, IS IT? changes as they come in. It may seem burdensome at the time, but there are potential benefits later. T erry at Midtown Pharmacy was dealing with another recurring frustration. Their usual generic brand of atenolol was backordered again. Terry ordered in a couple of 100 count bottles to hold them over until their usual brand was available __________________________________________________________ again. Terry didn’t bother to update their computer database to reflect this change because she would then just have to change it © Don R. McGuire Jr., R.Ph., J.D., is General Counsel at Pharmacists back again 2 days from now. The change isn’t really that important anyway, right? Mutual Insurance Company. Wrong. Your documentation is the only thing you will have later This article discusses general principles of law and risk management. It to prove what you did today. We all forget things, especially when is not intended as legal advice. Pharmacists should consult their own they come up weeks or months later. Consider the following claim attorneys and insurance companies for specific advice. Pharmacists scenario. should be familiar with policies and procedures of their employers and insurance companies, and act accordingly. A pharmacy was sued by a former patient over some faulty transdermal fentanyl patches. The patient alleged that he was injured due to the patch releasing the medication too quickly. The patient’s profile indicated that he received the patch manufactured by company A. Company A’s product had in fact been recalled due to this very problem. The patient was sure that the excessive dose delivered had caused him to be hospitalized. The pharmacy staff went through months of anxiety and expense while producing records and being deposed. What everyone learned at the end was that the patch received by the patient wasn’t manufactured by company A. He had received patches manufactured by company B. This was discovered when reviewing the invoices from the time period in question. Company B’s product had been purchased Agility is in the business of saving because of the recall of company A’s patches. However, the patient businesses. We bring together profile indicated that the patient had received Company A’s innovative products, affordable patches. Proper recordkeeping would have most likely prevented this pharmacy from suffering through months of litigation. services and, most important, great people – experts with the know-how A second consideration here is billing. In today’s world, it is more and passion to help you plan and important than ever to bill for what was actually dispensed. Third recover from disasters. Agility is the party payers expect and demand that their customers receive the difference between giving in to a product that is billed to the third party payer. While the 2 different fentanyl patches discussed above may be clinically interchangeable, crisis and surviving one. they are probably not the same when it comes to acquisition cost or reimbursement rates. One of them may have been non-formulary, for example. This difference is multiplied if one product is the brand name one. Clinically, none of the differences are significant. However, we aren’t talking about therapeutics. We are talking POWER TECHNOLOGY SPACE CONNECTIVITY finances and recordkeeping. This sort of discrepancy can lead to repayment demands, even penalties and interest, following an audit. The importance of recordkeeping shouldn’t be overlooked. In litigation, documentation is everything. If it wasn’t documented, it wasn’t done. Many cases have turned on seemingly small Agility Recovery is the endorsed provider of disaster recovery documentation issues. Perpetual inventory totals, timecards, services to the Washington State Pharmacy Association. For more delivery records, pick-up logs, documentation of counseling (or information call 720.490.4572 or visit www.agilityrecovery.com. refusal of counseling) are some other examples of records that Washington Pharmacy 31
  • 29. UPCOMING EVENTSImmunization PracticumApril 11, 2012 | Rosauers Supermarkets, Inc. | Spokane, WAThis program is designed specifically to train pharmacists and pharmacy students to participate in an Immunization program foradults and adolescents. The content derived from the CDC program “Epidemiology & Prevention of Vaccine-Preventable Diseases”and adapted to Washington State specific pharmacy law and practice. By completing this course, pharmacists can earn 15 hours ofcontinuing education credit while becoming certified to administer adult and adolescent vaccines.Clinical Pharmacology Series 2012: May 10, May 18, June 8, 2012Shoreline Conference Center | Seattle, WAThis series of five, one-day courses is designed as a pharmacology update at the advanced practice level. Sessions focus on currentrecommendations and controversies regarding drug therapy for common problems and include appropriate pharmacotherapeu-tic principles and recommendations for patient education. Teaching methods include lecture, discussion, and case analysis.Each day is structured as a separate course so that participants can attend those courses most pertinent to their needs. Partici-pants are encouraged to bring case studies for discussion with faculty.Northwest Pharmacy ConventionMay 31 - June 3, 2012 | Coeur d’Alene Resort | Coeur d’Alene, IDCome see the new renovations at the Coeur d’Alene Resort! Enhancements include a brand new lobby, fitness center, restaurants& lounge, additional meeting space, event center & garden, private lake view terrace, outdoor infinity pool with private cabanasand more! The 2012 Northwest Pharmacy Convention is the premier annual meeting place for the pharmacy communities ofWashington, Idaho and Montana. The event will feature 70 exhibits, more than 40 continuing education sessions and 500 phar-macy professionals who are interested in seeing and learning about all that is new in the world of health care. Make plans now tojoin us May 31-June 3 at the Coeur dAlene Resort in Idaho.Immunization PracticumJuly 19, 2012 | WSPA Office | Renton, WAThis program is designed specifically to train pharmacists and pharmacy students to participate in an Immunization program foradults and adolescents. The content derived from the CDC program “Epidemiology & Prevention of Vaccine-Preventable Diseases”and adapted to Washington State specific pharmacy law and practice. By completing this course, pharmacists can earn 15 hours ofcontinuing education credit while becoming certified to administer adult and adolescent vaccines.WSPF Scholarship ScrambleAugust 26, 2012 | Willows Run | Redmond, WAThe Washington State Pharmacy Foundation is proud to announce this year’s WSPF Scholarship Scramble will be held on August26, 2012 at Willows Run Golf Course. All proceeds from the Golf Scramble will go towards the Foundation’s mission to providescholarships for pharmacy students at Washington State University and University of Washington.2012 Annual MeetingNovember 1-4, 2012 | Great Wolf Lodge| Grand Mound, WAThis is truly a family event! Gather the latest information from pharmacy experts, exchange ideas with others facing similar chal-lenges, and build a personal and professional network while the family stays and plays! Each room is significantly discounted -$149/night, comes with four water park tickets, discounted spa rates, and is close to outlet malls and the Lucky Eagle Casino. Thisevent will feature exhibits, a variety of continuing education sessions, and our annual awards banquet honoring the finest in ourpharmacy community today.